Emergent Veno-arterial Extracorporeal Membrane Oxygenation Research Articles

Mortality in patients with normal left ventricular function requiring emergency VA-ECMO for postcardiotomy cardiogenic shock due to coronary malperfusion.

To analyze outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to postcardiotomy cardiogenic shock (PCCS) related to coronary malperfusion. Retrospective single-center analysis in patients with normal preoperative LVEF treated with VA-ECMO for coronary malperfusion-related PCCS between May 1998 and May 2018. The primary outcome was 30-day mortality, which was compared using the Kaplan-Meier method and the log-rank test. Multivariable logistic regression was performed to identify predictors of mortality. During the study period, a total of 62,125 patients underwent cardiac surgery at our institution. Amongst them, 59 patients (0.1%) with normal preoperative LVEF required VA-ECMO support due to coronary malperfusion-related PCCS. The mean duration of VA-ECMO support was 6 days (interquartile range 4-7 days). The 30-day mortality was 50.8%. Under VA-ECMO therapy, a complication composite outcome of bleeding, re-exploration for bleeding, acute renal failure, acute liver failure, and sepsis occurred in 51 (86.4%) patients. Independent predictors of 30-day mortality were lactate levels > 9.9 mmol/l before VA-ECMO implantation (odds ratio [OR]: 3.3; 95% confidence interval [CI] 1.5-7.0; p = 0.002), delay until revascularization > 278 minutes (OR: 2.9; 95% CI 1.3-6.4; p = 0.008) and peripheral arterial artery disease (OR: 3.3; 95% 1.6-7.5; p = 0.001). Mortality rates are high in patients with normal preoperative LVEF who develop PCCS due to coronary malperfusion. The early implantation of VA-ECMO before the development of profound tissue hypoxia and early coronary revascularization increases the likelihood of survival. Lactate levels are useful to define optimal timing for the VA-ECMO initiation.

CE-454610-1 VENTRICULAR FIBRILLATION REQUIRING EXTRACORPOREAL RESUSCITATION DURING RADIOFREQUENCY ABLATION IN THE CORONARY SINUS

Coronary vasospasm is a rarely reported but potentially catastrophic complication of radiofrequency ablation (RFA). The mechanism is not fully understood but may be related to thermal energy transfer, inflammatory markers released during ablation, and/or alterations in autonomic tone from stimulation of epicardial ganglionated plexi. While most vasospasm occurrences appear subclinical and self-limited, there are exceptions. To highlight an exceptional, life-threatening case of RFA-induced coronary vasospasm. N/A A 62-year-old man with persistent AF and five prior ablations (including one at our institution) presented for ablation of atypical atrial flutter. Termination of the flutter occurred with RFA (7 lesions) at the left atrial roof. There was also a breakthrough of conduction through a prior posterior mitral isthmus line, so coronary sinus (CS) lesions were placed to re-attain mitral block. Two irrigated RF lesions (#1 - 59 seconds, max 26 Watts; #2 - 40 seconds, max 33 Watts) were placed, but 7 seconds into the 3rd lesion (max 27 Watts), ventricular fibrillation (VF) occurred, initially refractory to multiple external shocks. ACLS/CPR commenced. Arterial access was rapidly achieved, and initial coronary angiography simply revealed diffusely slow/no flow related to ongoing VF. Emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation was initiated, following which the VF was successfully defibrillated, converting to sinus rhythm. Repeat coronary angiography revealed (known) minimal non-obstructive coronary disease as well as a focal, severe spasm of a dominant left circumflex artery adjacent to the location of CS ablation. Intracoronary nitroglycerin resulted in minimal initial angiographic improvement, so balloon angioplasty and deployment of a drug eluting stent was performed (post: TIMI III flow). The patient made a full recovery and was discharged home on post-procedure day 6 without long-term sequelae. This case underscores a life-threatening complication of RFA within the CS leading to coronary vasospasm and refractory VF. Expedient intervention with extracorporeal resuscitation and support can stabilize patients to allow time to manage arrhythmias and resolve spasm either pharmacologically or procedurally.

Abstract 15244: Rapid Recognition and Implementation of Mechanical Circulatory Support in Rare Fulminant Lymphocytic Myocarditis

Case Presentation: A 65 year-old woman with heart failure, nonischemic cardiomyopathy, atrial fibrillation, hypertension, prior stroke presented with chest pain and shortness of breath for three days. She was ill-appearing, hypotensive and tachypneic, with troponins reaching greater than 125,000 ng/L. Initial ECG demonstrated sinus rhythm with inferior ST elevations and lateral T wave inversions, however emergent catheterization revealed angiographically normal coronary arteries. Repeat 2D echocardiography showed sharp decline to ejection fraction (EF) 5-10%. Patient subsequently developed cardiogenic shock and despite inotropes, vasopressors and intra-aortic balloon pump, she suffered ventricular fibrillation arrest requiring defibrillation. This prompted escalation with emergent veno-arterial extracorporeal membrane oxygenation. Endomyocardial biopsy findings taken at that time were consistent with lymphocytic myocarditis with negative viral panel. Her hospital course was also complicated by acute renal injury, respiratory failure requiring intubation, metabolic acidosis and shock liver. With treatment with high dose steroids and mechanical circulatory support, the patient's severely diminished EF improved to 20% and she is undergoing placement of a left ventricular assist device. Discussion: Fulminant lymphocytic myocarditis is a rare disease that has clinically and pathologically distinct features from subacute or acute lymphocytic myocarditis particularly in its timeline of onset and features of hemodynamic compromise. It most frequently affects young and pediatric individuals and can result in significant mortality and morbidity. This case with an older patient with severe fulminant lymphocytic myocarditis confirmed on biopsy highlights: 1) the importance of early recognition affecting survival outcome, 2) golden standard for diagnosis with endomyocardial biopsy and immunohistochemical analysis for subtype-specific evidence-based treatment, and 3) integrated medical and surgical management, including mechanical circulatory support as an essential life-saving tool.

HYDROXYCHLOROQUINE CAN BREAK YOUR HEART

HYDROXYCHLOROQUINE CAN BREAK YOUR HEART

Change Of Heart: Interesting Case Of An Impella 5.5 Device Precipitating Electrical Storm And Right Ventricular Failure Treated With A Heart Transplant

<h3>Introduction</h3> Electrical storm (ES) due to ventricular arrhythmias is a life-threatening condition requiring emergent medical and mechanical intervention. <h3>Case</h3> A 60-year-old man with a history of nonischemic cardiomyopathy and ventricular tachycardia (VT) on sotalol and remote implantable-cardioverter implantation (ICD), already listed for transplant was admitted for shortness of breath at rest and worsening lower extremity edema. Physical examination; jugular venous pressure (JVP) of 12cm H₂O, S3 gallop, bibasilar rales on chest auscultation, and bilateral lower extremity edema with warm extremities. A right heart catheterization revealed a cardiac index of 1.6 with elevated filling pressures and blood pressure of 80s/50s mmHg. EKG showed chronic left bundle branch block with 1^st degree AV block. TTE reported severe MR and LVEF of 15 %. Sotalol was discontinued and IV diuretics with vasopressor support were attempted, but recalcitrant cardiogenic shock (approximately18 hours later) required escalation to mechanical support via Impella 5.5. Subsequently, i.e., 36 hours after Impella placement, the patient had multiple episodes of incessant VT requiring more than 20 ICD shocks complicated by cardiovascular collapse <b>(Figure 1)</b>. The patient was emergently intubated, deeply sedated, and initiated on Amiodarone and Lidocaine infusions (after bolus). Bedside TTE revealed evidence of RV failure with uncertainty regarding the distal tip of the Impella. He underwent emergent veno-arterial extracorporeal membrane oxygenation support (ECMO); transplant listing was upgraded to UNOS status I and he received a heart transplant within 24 hours. Post-operatively patient had no recurrence of VT and he was transferred to a skilled nursing facility 45 days later. <h3>Discussion</h3> Our case met the criteria for a ventricular or electrical storm as defined by 3 or more sustained episodes of VT/VF or appropriate ICD shocks within 24 hours. The etiology was deemed to be the nidus of severe structural heart disease <b>(Figure 2)</b> exacerbated by discontinuation of anti-arrhythmic and possible provocation of the myocardium by Impella. Appropriate interventions including combination IV antiarrhythmic agents, deep sedation, and ECMO were temporary measures deemed insufficient to curb the ES; therefore, transplant was the only best option. <h3>Conclusion</h3> ES may require emergent medical and drastic surgical interventions including ECMO. This case represents a unique clinical situation where the patient was essentially (and ultimately) "treated" with a donor heart transplant.

Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock

AimsWe investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and resultsBetween June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. ConclusionsOur study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China.

Severe cases of coronavirus disease 2019 (COVID-19) cannot be adequately managed with mechanical ventilation alone. The role and outcome of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19 is currently unclear. Eight COVID-19 patients have received ECMO support in Shanghai with seven with venovenous (VV) ECMO support and one veno arterial (VA) ECMO during cardiopulmonary resuscitation. As of March 25, 2020, four patients died (50% mortality), three patients (37.5%) were successfully weaned off ECMO after 22, 40, and 47 days support, respectively, but remain on mechanical ventilation. One patient is still on VV ECMO with mechanical ventilation. The partial pressure of oxygen/fractional of inspired oxygen ratio before ECMO initiation was between 54 and 76, and all were well below 100. The duration of mechanical ventilation before ECMO ranged from 4 to 21 days. Except the one emergent VA ECMO during cardiopulmonary resuscitation, other patients were on ECMO support for between 18 and 47 days. In conclusion, ensuring effective, timely, and safe ECMO support in COVID-19 is key to improving clinical outcomes. Extracorporeal membrane oxygenation support might be an integral part of the critical care provided for COVID-19 patients in centers with advanced ECMO expertise.

HIGH DOSE INSULIN AND VA ECMO FOR POISON-INDUCED CARDIOGENIC SHOCK

SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/09/2018 05:00 PM - 06:00 PM INTRODUCTION: High dose insulin therapy (HDI) is an emerging and increasingly well described intervention for poison-induced cardiogenic shock (PICS). PICS due to beta-blocker or calcium channel blocker overdose is both frequent and life-threatening [1]. When traditional therapies such as fluid resuscitation, cardiac pacing, atropine, calcium, glucagon, vasopressors and inotropes fail to provide hemodynamic stability, HDI can be effective [2-7]. While the current literature is limited to case series and animal models [2-7], we present a case of successful HDI in a patient with beta-blocker toxicity. CASE PRESENTATION: We report a 36-year-old female who presented in cardiogenic shock secondary to polypharmacy overdose, including significant amounts of propranolol. She suffered cardiopulmonary arrest shortly after arrival to the hospital. Despite aggressive resuscitation, she required emergent venoarterial extracorporeal membrane oxygenation (VA ECMO) support to achieve hemodynamic stability. HDI was subsequently initiated by assessing hemodynamic responsiveness to progressively increased bolus doses, starting with 1 unit per kilogram. HDI was continued with an insulin infusion at 15 units/kilogram/hour. She demonstrated an excellent response, and was successfully transitioned off VA ECMO support and all vasoactive medications. The following day, the insulin drip was carefully weaned to avoid large potassium shifts. The patient was eventually discharged to home, neurologically intact with normal biventricular function by echocardiogram. DISCUSSION: This patient demonstrated a rapid and robust response to HDI in the setting of profound cardiogenic shock. Despite requiring escalation of care to VA ECMO, HDI allowed for rapid discontinuation of this salvage therapy. Several mechanisms of action have been postulated for HDI, including a direct positive inotropic effect and multiple favorable metabolic properties [3,5,8-12]. HDI also induces vasodilation, which improves both microcirculation and systemic perfusion [5,11]. While evidence for specific dosing regimens remains limited, the doses used in this case are consistent with previously described values including bolus doses of 1 unit per kilogram and infusions of 10 units/kilogram/hour or more [13-15]. CONCLUSIONS: In patients with PICS due to either calcium channel blockers or beta-blockers, HDI can be a definitive and life-saving treatment. While large clinical trials are lacking, sufficient evidence exists to consider this therapy in patients with PICS refractory to traditional treatment [16]. Note: All sixteen references available in uploaded document Reference #1: DeWitt CR, et al. Pharmacology, pathophysiology and management of calcium channel blocker and beta blocker toxicity. Toxicol Rev 2004, 23:223-38 Reference #2: Yuan TH, Kerns WP, Tomaszewski CA, Ford MD, Kline JA. Insulin-glucose as adjunctive therapy of severe calcium channel antagonist poisoning. J Toxicol Clin Toxicol 1999, 37:463-74 Reference #3: Megarbane B, et al. The role of insulin and glucose (hyperinsulinemia/euglycemia) therapy in acute calcium channel antagonist and beta-blocker poisoning. Toxicol Rev 2004, 23:215-22 DISCLOSURES: No relevant relationships by Benjamin Abrams, source=Web Response No relevant relationships by David Douin, source=Web Response No relevant relationships by Scott Wolf, source=Web Response

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey

Context: Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Case details: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking “comfrey” tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove.Conclusions: The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.

Predictors of survival in VA-ECMO: Whom should we cannulate?

The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is becoming an increasingly frequent procedure in emergency medicine.1 Correct appraisal of clinical conditions and patient selection are critical not only in terms of expected outcome, but also in terms of adequate temporary support configuration, optimization of resources, and organization of daily hospital activities, since inappropriate implant may remarkably impact all these aspects. According to recent analysis of ECMO use in the USA,1 VA-ECMO was most commonly applied in post-cardiac surgery candidates, however with a constant decline for the period from 2007 to 2011. Indeed, from 57% of the total ECMO cases, post-cardiotomy VA-ECMO went to 38%, but with a significant rise in cases of cardio-pulmonary failure (from 3.9 to 11.1%).1 This situation is certainly further changing during the last 5 years as VA-ECMO in cardiogenic shock and cardiac arrest is becoming more popular. Cardiac arrest: Patient selection in this setting is rather variable. However, potential cardiac etiology (acute myocardial infarction – AMI) represents almost 50% of the causes, and witnessed cardiac arrest, immediate cardio-pulmonary resuscitation (CPR) by bystanders, adequate CPR (possibly with mechanical cardiac massage devices), and not prolonged time from cardiac arrest to ECMO application ( &lt; 60 min) represent positive predictors in the setting of extracorporeal cardio-pulmonary resuscitation (ECPR).2 Recent publications have shown that ECPR might achieve respectful outcome also in elderly patients.3,4,5 Therefore, age should not disqualify potential candidates. Absence of severe acidosis and still acceptable end-tidal CO2 may represent additional elements for patient selection in this setting. Post-cardiotomy: ECMO results in this setting appear rather unsatisfactory with in-hospital survival below 30%.5 Prompt initiation of ECMO and avoiding unnecessary prolonged cardio-pulmonary bypass and metabolic as well as coagulation derangement are among the most relevant key factors. The absence of severe cardiac or co-morbidities prior to surgery and the expected temporary impairment of the cardio-respiratory systems represent additional indications for post-cardiotomy ECMO. Cardiogenic shock: This setting represents the most expanding field of ECMO application. Indications may derive from refractoriness of cardio-circulatory impairment to conventional therapies (drug and IABP). Moreover, in this setting, advanced age and severe co-morbidities may represent relative contraindications. Furthermore, in this field, the potential for cardiac recovery or the possibility to bridge the patient to other treatments, if recovery is considered unlikely, represents indication for ECMO use. Respiratory distress: VA-ECMO is generally indicated if right ventricular dysfunction is present or develops, and if VV-ECMO does not provide sufficient peripheral oxygenation. In the last case, hybrid configuration (VVA or VAV) might be more suitable and advisable. Uncommon indications: Sepsis, trauma (most often treated with VV-ECMO), fulminant myocarditis, Tako-Tsubo, or complicated interventional procedures (TAVI, PCI, balloon valvuloplasty) represent areas in which ECMO is increasingly applied.6,7 Despite wider use in these settings, more clinical evidences are still needed to conclusively define patient selection criteria and ultimate benefits. Finally, a developing indication might be prophylactic VA-ECMO in critically ill patients undergoing either cardiac surgery or interventional cardiological procedures. In these patients, in whom post-procedural severely complicated course is expected, timely and pre-crash support may help to provide a smooth peri-procedural period. Short-time controlled support of cardio-circulatory system and peripheral organ perfusion, with avoidance of metabolic and hemodynamic derangement, may also affect emergency VA-ECMO implant should patient deterioration occur, and allow a better complicated patient management with better final outcome.

Completeness of Revascularisation Increases Survival and Weaning Success in Patients with Myocardial Infarction-Induced Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support

Objectives: Aim of this study was to investigate the prognostic outcome of patients with AMI and profound CS in patients receiving emergency veno-arterial extracorporeal membrane oxygenation (va-ECMO). Methods: A consecutive series of 81 patients with AMI and severe CS receiving emergency va-ECMO from 1997 to 2015 in was investigated. Outcome evaluation regarding in-hospital mortality, “bridge to recovery” and long-term outcome in patients with successful weaning from va-ECMO was performed. Kaplan Meier survival analysis was performed to identify relevant prognostic parameters predicting weaning from va-ECMO and patient survival. Permission to perform this study was obtained from the local IRB. Results: Mean patient age was 58.8 ± 10.0 years and 77.8% were male gender. Out-of-hospital mechanical cardiopulmonary resuscitation (CPR) was performed in 7 patients (8.9%), within the cath-laboratory in 18 patients (24.1%) and during surgical insertion of va-ECMO in 20 patients (25.3%). Initial installation of intra-aortic-balloon counter-pulsation (IABP) was sustained in 33 patients (41.8%). De novo MI was responsible for 43 (53.1%) of cases, acute stent thrombosis in 13 (16.0%), and complications resulting from PCI were responsible for MI in 30.9%. Mean duration of va-ECMO support was 5.9 ± 5.4 days. Mean time from onset of MCI to reperfusion was 5.4 ± 3.9 hours. Mean “door-to-reperfusion-time” was 1.35 ± 1.2 hours. Actuarial 30-day survival was 52.6%, 43.8% at 1 year and 36.4% at 5 years. Restoration of spontaneous circulation enabling bridge to recovery and weaning from va-ECMO was possible in 33 patients (46.8%) and was significantly higher in patients with complete revascularisation (p = 0.026). Bridge to recovery was significantly higher in patients with va-ECMO and consecutive coronary artery bypass grafting (CABG) versus patients with culprit lesion PCI (p = 0.011). In patients successfully weaned from ECMO, CABG patients demonstrated significantly higher long term survival than PCI patients (log-rank: p = 0.04). Conclusion: AMI complicated by cardiogenic shock is associated with a high in-hospital mortality even in patients undergoing emergency va-ECMO. Complete revascularisation significantly improves weaning success from va-ECMO and long term survival. Complete revascularisation seems to be better provided by CABG rather than PCI only - therefore weaning and long term prognosis is significantly improved by consecutive CABG rather than PCI or consecutive conservative management.

The role of the total artificial heart in the treatment of post–myocardial infarction ventricular septal defect

improved durability and performance relative to previous VADs. Our major rationale for choosing the HeartWare HVAD was its relatively small size and ability to be contained within the pericardium, thus eliminating the potential need to create a pocket or rotate the pump configuration. In addition, the device’s integrated inflow cannula could decrease the chance of inflow obstruction related to the abnormal position of the ventricles in CC-TGA. TEE guidance ensured successful selection of the optimal insertion site for the VAD inflow cannula. In summary, we report a case of successful HeartWare HVAD implantation in a patient with CC-TGA to support the function of the RV (systemic ventricle).

Successful extracorporeal membrane oxygenation weaning after cardiac resynchronization therapy device implantation in a patient with end-stage heart failure

We present the case of a 46-year old male with end-stage heart failure due to ethyltoxic cardiomyopathy. The patient did not meet the criteria for heart transplantation and declined left ventricular assist device implantation. We decided to conduct cardiac resynchronization therapy defibrillator (CRT-D) implantation. Under general anaesthesia for CRT-D implantation, cardiac function worsened. Due to deteriorating haemodynamics, CRT-D implantation was aborted and emergent veno-arterial extracorporeal membrane oxygenation (ECMO) implantation was performed. Subsequent weaning from ECMO was not possible. We decided to proceed with CRT-D implantation while still on ECMO support. With biventricular stimulation, cardiac function improved promptly and the patient could be weaned from ECMO the same day.

Outcomes of percutaneous femoral cannulation for venoarterial extracorporeal membrane oxygenation support

We report and examine the outcomes of emergency venoarterial extracorporeal membrane oxygenation (ECMO) support initiated via percutaneous cannulation of the femoral vessels. Fifteen patients undergoing percutaneous venoarterial ECMO under emergency circumstances between January 2009 and July 2011 were identified. The implantation technique employed the Seldinger's technique for both arterial and venous cannulae. Whenever possible antegrade perfusion of the ipsilateral lower limb was performed through percutaneous catheterization of the superficial femoral artery (SFA). ECMO support was indicated mainly for cardiac arrest (n=9, 60%) or cardiogenic shock (n=4, 27%), while two (13%) patients required ECMO support for acute respiratory failure. In five (33%) patients, ECMO was implanted during cardiopulmonary resuscitation manoeuvres. ECMO support was maintained for a mean of 4.9 days. Eight patients (53%) were successfully weaned from the device. Thirty-day mortality was 53%. Seven patients (47%) suffered early complications, namely two wound infections, one thrombosis of the venous cannula, one erroneous implantation of the arterial cannula into the femoral vein, one local dissection of the femoral artery, one retroperitoneal bleeding and one acute limb ischaemia. No long-term vascular complications were noted. Percutaneous femoral cannulation for ECMO support remains a prompt approach for establishing extracorporeal circulatory support in acute cardiopulmonary failure when conditions for performing femoral vessel cut down are not optimal. However, vascular complications are frequent and carry a significant morbidity and mortality.

Over 2-year disease-free survival after multimodality therapy of a primary cardiac lymphoma

This comment deals with our study regarding the innovative, sequential therapy of a primary cardiac lymphoma. Primary cardiac T-cell lymphoma is defined as a non-Hodgkin lymphoma (NHL) involving only the heart and/or the pericardium, or as an NHL with the main bulk of the tumor located on the heart. It is an extremely rare disease with a typical heterogeneous clinical manifestation and 100% mortality if left untreated. Herein we describe a clinical follow-up of 26 months in a young female patient with eventful heart failure due to the uncommon diagnosis of a primary cardiac T-cell lymphoma. The patient underwent emergent veno-arterial extracorporeal membrane oxygenation (ECMO) implantation with the suspicion of a fulminant viral myocarditis. When rapidly complete contractile cardiac arrest and an almost complete obliteration of the ventricular lumen occurred within 1 day of emergency cardiectomy, implantation of a custom-made biventricular assist device (BVAD) was done and 12 days later successful heart transplantation was performed. In addition, she underwent chemotherapy (CHOP regime) and reduced immunosuppression, always maintained in the subtherapeutic range. The first myocardial biopsy, 2 weeks after transplantation, the patient showed single tumor cells within the graft, but all consecutive biopsies confirmed complete resolution of T-cell infiltration. Six months after transplantation endomyocardial biopsies revealed mild rejection, which was successfully treated with bolus steroids. At 1 year, heart catheterization showed no transplant vasculopathy and a normal ejection fraction of 65%. Severe facial actinomycotic infection occurred on a single occasion, which was treated successfully with surgery, antibiotics and antimycotics. Most recently, more than 2 years later, routine staging, including clinical examination, computed tomography (CT) scans, ultrasound evaluation and endomyocardial biopsy, indicated no evidence of tumor recurrence. The last endomyocardial biopsy showed no rejection (A0, ISHLT 0R). Except for persistently impaired renal function, without the

Extracorporeal membrane oxygenation as a bridge to lung transplantation in a patient with persistent severe porto-pulmonary arterial hypertension following liver transplantation

Idiopathic pulmonary artery hypertension (IPAH) is a progressive disease with a dismal prognosis and lung transplantation is often the only option for patients, who do not respond to pharmacological therapy. We report the use of an extracorporeal membrane oxygenation (ECMO) system in a 49-year-old woman with primary pulmonary hypertension, previously liver transplanted. The patient, listed for lung transplantation, developed respiratory and circulatory failure despite maximal pharmacological therapy and was successfully bridged to emergent bilateral lung transplantation with veno-arterial ECMO. Emergent veno-arterial ECMO was able to rescue the patient and bridge her to bilateral lung transplantation and should therefore be an option for patients with PAH and circulatory collapse.

Percutaneous venoarterial extracorporeal membrane oxygenation for emergency mechanical circulatory support

In this retrospective study we report our initial experience with percutaneous venoarterial extracorporeal membrane oxygenation in the emergency treatment of intractable cardiogenic shock or pulseless electrical activity. Between January 1994 and July 1995, percutaneous venoarterial extracorporeal membrane oxygenation was attempted in seven patients (pulseless electrical activity, five patients; cardiogenic shock, two patients). In two of the seven patients, efforts at arterial cannulation resulted in cannula perforation at the level of the iliac artery. In the remaining five patients, percutaneous venoarterial extracorporeal membrane oxygenation could be established and was maintained for 3–84 h. Major bleeding remained a common complication during extracorporeal membrane oxygenation despite the use of heparin-coated bypass circuits and was responsible for death during extracorporeal membrane oxygenation in one patient. The remaining four patients could be weaned from mechanical circulatory support within 24 h, two after surgical interventions (resection of right atrial tumor, heart transplantation), one after thrombolytic therapy. In one patient, cardiac function recovered spontaneously after 6 h on venoarterial extracorporeal membrane oxygenation. Three patients were discharged from hospital, two of them made a full recovery, one sustained severe hypoxic brain injury. A few patients with intractable cardiogenic shock or pulseless electrical activity can be resuscitated with the help of emergency percutaneous venoarterial extracorporeal membrane oxygenation. Emergency venoarterial extracorporeal membrane oxygenation is associated with a high rate of complications and its use should therefore be limited to selected patients with a rapidly correctable underlying cardiopulmonary pathology (anatomic, metabolic or hypothermic) who do not respond to conventional advanced cardiac life support.